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<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Untitled Document</title>
</head>

<body>
<form id="infoform" name="infoform" method="post" action="">
  <center>
    <h3>Personal Information</h3>
    <p align="left">
      <label>&nbsp;&nbsp;Acount Number:
      <input type="text" name="acountnumber" id="acountnumber" readonly="readonly" />
      </label>
    </p>
  </center>
  <label>
  &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;First Name:
  <input type="text" name="firstname" id="name" tabindex="1" />
  &nbsp;&nbsp;Last Name:
    <input type="text" name="lastname" id="lastname" />
  Middle Initial:
  <input type="text" name="middleinitial" id="middleinitial" />
  </label>
  <label>  </label>
  <p>
    <label></label>
    <label></label>
    <label>&nbsp;&nbsp;&nbsp;&nbsp;Street Address:
    <input type="text" name="streetaddress" id="streetaddress" />
    </label>
    <label> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;City:
    <input type="text" name="city" id="city" />
    </label>
    <label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;State:
    <select name="state">
      <option value="NH">NH, New Hampshire</option>
      <option value="MA">MA, Massachusetts</option>
      <option value="NY">NY, New York</option>
      <option value="CA">CA, California</option>
      <option value="VT">VT, Vermont</option>
      <option value="ME">ME, Maine</option>
    </select>
    </label>
  </p>
  <p>
    <label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Zip Code:
    <input type="text" name="zipcode" id="zipcode" />
</label>
    <label> Home Phone:
    <input type="text" name="homephone" id="homephone" />
    </label>
    <label>&nbsp;&nbsp;&nbsp;Cell Phone:
    <input type="text" name="cellphone" id="cellphone" />
    </label>
    <label></label>
  </p>
  <center><h3>Donation Information</h3></center>
  
  <p>
    <label>Donation Amount:
    <input type="text" name="donationamount" id="donationamount" />
    </label>
  </p>
  <p>&nbsp;</p>
  <p>&nbsp;</p>
  <p>&nbsp;</p>
</form>
</body>
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